What is an intensive care specialist?

Neil R Orford
Med J Aust 2019; 211 (7): 312-313. || doi: 10.5694/mja2.50337
Published online: 7 October 2019

We are not viewed or valued by our community through a lens of disease, machines and location

“What do you do for a living?” A simple question. A natural conversation progression in so many settings. At social gatherings, school functions, passing time with Uber drivers in peak hour traffic, sharing elbow space on planes, side‐by‐side leaning on fences watching weekend sport. Yet after 20 years, I still fumble the answer.

The first part is simple. “I am an intensive care specialist.”

Then a pause. I wait and watch for a flicker of recognition. A sign I am facing someone with their own memories of intensive care for a loved one, perhaps even themselves. This is the minority, and they do not require an explanation.

It is with the majority, those who look at me blankly, with no lived experience of intensive care, that I fumble the answer. After the pause, the absence of recognition, I try to explain intensive care. I am not good at this, and the same pattern plays out. Enthusiastic mistaken identity on their part, confusing description of disease and logistics by me, then divergent images of my working life. Enthusiastic mistaken identity that I am a surgeon, emergency physician, or cardiologist. “You're not operating today?”, “I was in emergency with my daughter last week, you must see some wild things”, “My mother had a stent in her heart with you”. It is tempting to simply nod, leave them with the certainty of assigning me a respectable identity. Before I burst the bubble, I briefly and fondly recall my son's primary school assembly many years ago. Showing the early signs of a persistent flair with microphone and crowd, he confidently announced to the assembled Year 4 students that his dad was an intensive care doctor, a man who saves lives by operating on hearts and brains. As the applause engulfed me, I half‐heartedly considered the complexities of setting the record straight. Then I smiled, nodded, soaked in the adoration, and everyone was happy.

Instead, I take a deep breath and embark on a confusing description of technology, mechanics and disease. A brief monologue of providing organ support with machines after major surgery, severe infections, trauma or breathing difficulties. I describe how patients with these diseases need care in a “special” part of the hospital, an open plan technical space with monitors. By now, they look thoroughly confused, so I desperately resort to waving at the room around us, making pointless comparisons to the size of an intensive care unit (ICU). Gradually, I sputter to a stop, mid‐sentence, and look at them apologetically. Another pause. “That must be interesting.” We move on to some other topic, possibly with them imagining I work in a small airport departure terminal with beds.

What do I do for a living? Perhaps I should listen and learn from those who recognise my role. They do not speak of diseases, machines or physical spaces. They pause, share often painful memories of an immensely vulnerable period of their life, and have only one question. “How do you cope with this day in day out?” Perhaps I should take their lead and tell a story of what I am to our patients and what they are to me. We all have these stories.

A few years ago, I sat at a Year 12 graduation ceremony, in a sea of parents and family. As my son walked across the stage to mark the end of his school life, I felt the mix of joy, pride and wistful sadness I believe many of us feel at major life transitions. Then I watched a young woman, the daughter of a friend, walk proudly across the stage. My wife squeezed my hand and I swallowed the sob of relief that unexpectedly overwhelmed me. As the ceremony ended, her family waited for me while the crowd filed out. I walked over, not knowing what to say, her mother simply hugged me tight, and we walked out together, with smiles on our lips and tears in our eyes.

A year earlier, on a routine school day, while my son was sitting on the school bus this young woman should have been on, she was being carried into our emergency department by her frantic mother and brother. The severity of her shock led to rapid escalation of care, and as the duty intensivist, I attended emergency immediately. The site of a mottled, shocked, pre‐arrest teenager was compelling, so it was only when her mother called me by name that I realised I was looking at a friend and her daughter. By the time her schoolmates finished morning classes and emerged into the sunlight, she was ventilated, on multiple vasopressors, renal replacement therapy, and progressing to multi‐organ failure due to septic shock. While the school term passed by, she was slowly separating from ventilation, celebrating the removal of her tracheostomy and restart of her kidneys, and learning to walk on limbs with atrophied muscles and nerves. Watching her walk, confidently and unaided across a stage in front of her family was a celebration of what our health system, our ICUs and we achieve on a daily basis. I felt the joy, gratitude and pride to have been a part of her care, for this to be my part in our community.

I also sometimes feel apart, a step outside my community, separated by the nature of my profession. Mid‐way through her month in ICU, her progress had slowed from delirium, weakness and secondary infections, the usual suspects in chronic critical illness. The day we inserted her tracheostomy, I went home, sat on our front steps, and wept while my wife sat quietly beside me with her arm around my shoulders. The exaggerated burden of providing care for someone I knew, the fear I might not be able to return her to her family undamaged, the despair her family and friends might feel for years to come, even the projection on to my own daughter were overwhelming.

Years after caring for the father of a nurse from another hospital, I stood next to her watching a junior football match. Her father's death had been unexpected, a sudden abdominal crisis in an independent older man with significant comorbidity, resulting in laparotomy, septic shock, multi‐organ failure, a switch to palliative care, and a comfortable death. I had not seen the daughter for over a year, and the conversation quickly turned to her father. She told me the care had been wonderful and grief was receding. She paused and then told me that every time she saw me it reminded her of her father dying and worsened her grief. She apologised and walked away. She alone in her grief, I alone in the crowd.

There is more to tell than the rewards of gratitude and pride and the burden of experiencing others suffering. If I still have their attention, I can describe my endless curiosity, passion for the evolving logic and evidence in critical care, and my sense of belonging in the complex environment of doctors, nurses, allied health, patients and families.

Maybe it is time to change my answer. To stop trying to create an image through a lens of disease, machines and location. To acknowledge we are not viewed or valued by our community on these criteria. Maybe it is time to describe our profession through the lens of what we mean to our patients and what they mean to us.

Provenance: Commissioned; not externally peer reviewed.

  • Neil R Orford1,2,3

  • 1 University Hospital Geelong, Geelong, VIC
  • 2 Deakin University, Geelong, VIC
  • 3 Monash University, Melbourne, VIC


Competing interests:

No relevant disclosures.


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